Developing and implementing a

personal protective equipment training

programme for high consequence
infectious disease preparedness

Ruth Barratt RN, BSc, MAdvPrac (Hons)

CNC Infection Prevention and Disease Control (Biopreparedness)

Hosted by Jane Barnett

jane@webbertraining.com

www.webbertraining.com February 19, 2020

 Disclosure
• I have no actual or potential conflict of
interest in relation to this presentation

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 Acknowledgements
• Dr Mary Wyer, Westmead Institute for
Medical Research and WSLHD
• State of Biopreparedness Committee,
Westmead Hospital
• Infection Prevention and Control Team WH
• Westmead staff who trained in high-level PPE
• Professor Lyn Gilbert, University of Sydney

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 Background
• Using video-reflexive ethnography to improve
PPE use
• Invited to use VRE in high-level PPE training
• IPC and educator expertise
• Developed a comprehensive training
programme for high-level PPE
• Current roles are federal-funded positions for
NSW biopreparedness

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 Key influential documents
• Alison Sykes 2019: An International Review of High Level Isolation Units
• Alberta Health Services & University of Calgary 2015: Human Factors Evaluation
of Simulated Ebola Virus Disease Patient Scenarios: System Factors Associated
with Donning and Doffing During Triage, Treatment and Transport
• NETEC - The National Ebola Training and Education Center - https://netec.org/
• Numerous research articles related to safe doffing and PPE

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 Outline of presentation
• Introduction to HCID
• What we have done so far to prepare for HCID
– Hierarchy of controls
• Facility
• Policy
• PPE
• Developing and implementing the training
programme

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MSF worker-2019 Ebola DRC
iAfrica

South Korea - 2015 MERS outbreak

Korea Financial Times

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High Consequence Infectious Diseases (HCID) 1
• Acute infectious disease
• Typically has a high case-fatality rate
• May not have effective prophylaxis or treatment
• Often difficult to recognise and detect rapidly
• Ability to spread in the community and within
healthcare settings
• Requires an enhanced individual, population and
system response to ensure it is managed effectively,
efficiently and safely
1 UK Government 2019
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 HCID
Contact transmission
• Viral Haemorrhagic Fevers
– Ebola virus disease (EVD)
– Lassa fever
– Marburg virus disease (MVD)
Airborne transmission
• 2019-nCoV acute respiratory
disease
• Avian influenza A
– H5N1
– Other novel human pathogenic
influenza
• Severe acute respiratory
syndrome (SARS)
• Middle East respiratory
syndrome (MERS)
• Monkeypox

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 HCID threat
• 2014-2016: West Africa Ebola Zaire outbreak
– 28,616 people affected, 11,310 deaths
• 2014: MERS outbreaks
– Middle East but also S Korea
– Hospital transmission
• 2018 – present: EVD Democratic Republic of the Congo
– Public Health Emergency of International Concern (WHO
2019)
– 3421 cases / 2242 deaths / 1154 survivors (as of 28/1/20)
• 2019 – present 2019-nCoV acute respiratory disease

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 Local HCID preparedness
• Westmead Hospital in
Sydney – state facility for
NSW (adults)
• Isolation facilities - existing
and new
• HCID policies and
procedures
• PPE
• Staff training

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 Local HCID preparedness
• Build on work done in 2014-2015 and with
SOB project team
• DRC outbreak renewed efforts to be prepared
as the state facility
• Training programme linked to other HCID
preparedness activities e.g. policies revised
• Appointment of small multi-disciplinary team

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Preventing transmission –
hierarchy of controls

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 Engineering controls
• Europe - high level Trexler isolator – Royal
isolation units
Free Hospital, UK
– 4 in UK
• USA - biocontainment
units
– 10 regional
• Australia – infectious
disease units /
biocontainment units
– 1 per state
• NZ – I purpose built

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 Westmead engineering controls
• Current: 2 Q-class rooms for adults
– Dedicated beds in the ICU
– Anteroom, patient room with ensuite
– Utility room A
– Staff shower
– Utility B for transfer of waste, blood samples etc.
• New: state of the art biocontainment unit
– Paediatric and adult beds

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Q-class rooms

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 Engineering controls
• Organisation of PPE supplies in
donning area
• Build upon existing dirty and clean
zones
• Tape on floor for doffing
• Minimal equipment/supplies in room
– Checklist with photos
• Signage
• Hands free ABHR dispenser
• Cuff first gloves dispenser

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 Administrative controls
• Operational procedures to prevent/minimise exposure
– Buddy system
– Change in practice to minimise entries
↓ number of people exposed
↓ doffing risks
– Clinical interventions – radiology, IV, dialysis
– Waste
– Environmental cleaning
• Training
– Donning and doffing PPE
– Procedures
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Operational procedures – doing the job
• The safety of staff MUST take
precedence over patient
safety
– BUT, the patient is a person
• Confidence in PPE protection
• Understanding transmission
routes
• Adapting IPC principles to
the physical space
• Using a Buddy

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 Buddy responsibilities
• Being vigilant in spotting defects or breaches in PPE while
HCWs are in the patient room
• Observing HCWs for heat stress or fatigue related to PPE
• Monitoring compliance with PPE protocols
• Guiding, correcting, and assisting during donning and doffing
• Adhering to the Call / Do / Respond method
• Warning HCWs of potential risky actions (e.g., touching face)
• Being informative, supportive and well-paced in issuing
instructions or advice
• Protecting themselves through proper PPE use during doffing
• Anticipating and planning for risks

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 Specific procedures
• Cleaning up a blood or
body fluid spillage
• Phlebotomy and
preparing the samples
for transport to the
laboratory
• Transferring waste bags
from the dirty zones
• Procedure for changing
outer gloves

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 Training
Train specifically for knowledge and skills relating to:
• Self-awareness of habitual behaviours and the importance of
minimizing them
• Hazard identification, awareness of where contamination may
occur and knowledge of how to respond appropriately should
contamination occur.
• Familiarity with PPE, specifically how it will affect HCW mobility
and dexterity, as well as how their body reacts to heat stress.
• Procedural competency, repetitive training including appropriate
technique for the motions associated with doffing PPE and checklist
use.
• Buddy roles that support HCW including the management of PPE
breaches, minimising the spread of contamination, and avoiding
high risk behaviours.

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 Personal Protective Equipment
• PPE based models of
delivery
– Different PPE ensembles
– No global consensus on
individual PPE items
• PPE is unfamiliar and
constraining
• High probability of error
when doffing – self
contamination

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 PPE checklists
• Checklists used for both donning and doffing
– Used video reflexivity to improve checklists and
doffing procedures
– Learn from healthcare workers
• Buddy system used (trained observer)
– Consider a third person if resources allow
• CALL, DO, RESPOND method
– Physically tick the check list
– Include regular reassurance (doffing)
• Minimise steps that require the Buddy to touch
the HCW when doffing
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 Selection of PPE
PERSONAL PROTECTIVE EQUIPMENT
• Availability – currently / in 1. Hospital scrubs 2. Non-slip socks

global emergency
• Gowns versus coveralls with 3. Rubber clogs 4. Booties

mask or PAPR
• Adequate coverage
• Protection for mucous
5. N95/P2 mask 6. Hood

membranes
• Ability to move and work in 7. Inner gloves 8. Gown

PPE OR

• Ease in doffing – minimises 9. Face shield 10. Outer gloves

breaches
• Staff acceptance

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 Gowns & Coveralls
Gown Coverall
• Surgical gown • Protection level
– knitted cuffs • ? Hood or no hood
– wrap around (coverage)
• Integral finger loops (middle
• AAMI 4 level - whole gown finger)
• Weight - comfort • No integral feet (trip hazard)
• Length • Covered zipper
• Fit & sizing • Zipper cord
• Neck fastening (doffing)

Additional plastic apron or gown?

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 Gloves
• Different colours for inner and
outer
• Long cuffs e.g. chemotherapy
gloves
• Thickness – dexterity
• 2 pairs or 3 pairs
• Taping of gloves
– ease of removing tape – no scissors
– longitudinal or circumference
– risk of tearing gown
• Glove dispenser – cuff first

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 Face and head cover
• Mask over or under hood
• Goggles and/or face visor
• Hood with shroud
– Material
– Fit
– Availability
• PAPR
– Availability of suitable hood
– Motor outside or concealed
• Disposable versus reusable

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 Foot coverings
• Plastic shoes
– Colour coded for size
– Easily disinfected
• Booties
– Long enough with gown
– Non-slip sole
– Ties versus elastic
– 2 sizes

Note: The booties are the trickiest item to remove

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 Other PPE items
• Scrubs – disposable scrubs were transparent
• Sports bands for personal glasses
• Non-slip socks
• Hair ties and clips
• Anti-fog spray
• Tape
• Permanent marker

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 Training programme
• Aims and learning outcomes
– To equip participants with the ability to understand
and demonstrate safe donning and doffing of high-
level PPE
– To give clinicians the experience of performing
common procedures while wearing full PPE
– To understand the role of the Buddy
• Use of WSLHD lesson plans
• Incorporate video-reflexive ethnography as a
learning tool

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 Video reflexive ethnography
• Video clinicians working in and
doffing PPE
• Show the footage to them
individually or in groups for
reflexive discussion
• Makes explicit the complex reality
of high-level PPE
• Assists clinicians make sense of
their own PPE practices and
contexts – self-awareness
• Leads to improvements in
individual behaviour and
procedures

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 Planning
• Attendees
– Emergency Department
– Infectious Diseases
– Critical Care
– Public Health
– IPC
• Content:
– Theory
– Classroom
– Simulation
– Debrief
• Numbers limited by:
– Space for demo and practical component in classroom
– Opportunities in Q-class rooms
– Expert feedback

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 Planning (cont.)
• Training time:
– Pre-training - watch video for Beak method of
safe glove removal methods glove removal
– 8 hours initial training day
– 4 hours credentialing session
– 1 hour 3-month refresher
• Admin
– Training day preparations
– Data entry – PPE sizes,
credentialing etc

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 8-hour day - morning
• PPT intro – 1hr
• PPE sizing and
collection of items &
brief tour of Q-class
rooms
• Demonstration of
donning and doffing
PPE then practice
• Videos of procedures

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Classroom demo and practice

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 8-hour day - afternoon
• Practice donning and
doffing in real space
• Practice being a Buddy
• Practice undertaking
procedures in PPE
• Debrief
• Evaluation

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 4 hours for credentialing
• Requires 5 practices
– 1 counted from 8-hour day
• Don and doff 4 times
– Assessed on final
– Re-use gown, hood, visor
and booties
• Maximum 4 people
– 2 persons per session per Q-
class room
– 2 assessors (experts)
• Competency tool based on
state but revised in-house
• Include research follow up

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 Refresher training
• 3 month in normal time
– More frequently if alert
locally/nationally
• Don and doff x 1
• Act as doffing Buddy
• Ideally 2 persons
• In real space
• Incorporate other procedures
if time allows
• Minimum 1 hour

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 Summary
• >50 people have now completed the initial
training, credentialing and 3-month refresher
• Resource intensive – time!
• Benefit by having a dedicated space always
available
• Inclusion of research useful and clinician
opinion critical to confidence of staff in using
PPE

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 Conclusion
• Preparation for HCID is important for public
health and protection
• Training in routine and high level safe donning
and doffing PPE is an essential component of
preparedness
• Planning should allow for resources and
sustainability

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A bit of fun – a pandemic limerick
• There was an infectious
disease
• Which brought the whole
world to its knees
• When they sneezed and
they coughed
• We donned and we
doffed
• And survived with barely
a sneeze

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